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    Central Neuraxial Blocks: Dr. Anilkumar T.K. Anaesthetist, NMC Hospital, Abudhabi, UAE

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    ansa1997
    This document provides an overview of central neuraxial blocks including spinal and epidural anesthesia. It discusses vertebral anatomy, indications for spinal blocks, physiological effects, complications like post-dural puncture headache, treatment for complications, and precautions for neuraxial anesthesia in patients taking anticoagulants. It also reviews fasting guidelines to reduce the risk of pulmonary aspiration.

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    Central Neuraxial Blocks: Dr. Anilkumar T.K. Anaesthetist, NMC Hospital, Abudhabi, UAE

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    ansa1997
    53 views39 pages
    This document provides an overview of central neuraxial blocks including spinal and epidural anesthesia. It discusses vertebral anatomy, indications for spinal blocks, physiological effects, complications like post-dural puncture headache, treatment for complications, and precautions for neuraxial anesthesia in patients taking anticoagulants. It also reviews fasting guidelines to reduce the risk of pulmonary aspiration.

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    Central Neuraxial Blocks

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    This document provides an overview of central neuraxial blocks including spinal and epidural anesthesia. It discusses vertebral anatomy, indications for spinal blocks, physiological effects, complications like post-dural puncture headache, treatment for complications, and precautions for neuraxial anesthesia in patients taking anticoagulants. It also reviews fasting guidelines to reduce the risk of pulmonary aspiration.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    53 views39 pages

    Central Neuraxial Blocks: Dr. Anilkumar T.K. Anaesthetist, NMC Hospital, Abudhabi, UAE

    Uploaded by

    ansa1997
    This document provides an overview of central neuraxial blocks including spinal and epidural anesthesia. It discusses vertebral anatomy, indications for spinal blocks, physiological effects, complications like post-dural puncture headache, treatment for complications, and precautions for neuraxial anesthesia in patients taking anticoagulants. It also reviews fasting guidelines to reduce the risk of pulmonary aspiration.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 39

    CENTRAL NEURAXIAL BLOCKS

    Dr. Anilkumar T.K. Anaesthetist, NMC Hospital, Abudhabi, UAE

    VERTEBRAL ANATOMY

    SALIENT FEATURES
    1. Spinal Cord ends at lower border of L1 in adults, L3 in infants 2. Line joining the iliac crests is at L3-L4 interspace

    3. Epidural Space lies between the walls of vertebral canal & the spinal dura mater

    SPINAL BLOCK
    1. Indications
    2. Landmarks 3. Technique

    4. Drugs
    5. Physiological Effects 6. Contraindications - Absolute - Relative 7. Complications

    PHYSIOLOGICAL EFFECTS
    1. Nervous system - Differential nerve blockade - Interindividual variability of nerve root sizes 2. Cardiovascular System - Hypotension - Bradycardia

    3. Respiratory System - Decrease in Vital Capacity - Apnea


    4. Gastrointestinal System - Constricted Gut - Nausea/Vomiting 5. Renal System - Urinary Retention

    COMPLICATIONS
    1. Post Dural Puncture Headache 2. Urinary Retention

    3. Labyrinthine Disturbances
    4. Cranial Nerve Palsy 5. Spinal Cord Trauma

    POST DURAL PUNCTURE HEADACHE


    Pathophysiology of Dural Puncture - Leakage of CSF - Excess loss of CSF - intracranial hypotension - reduction in CSF volume

    Actual Mechanism - Low CSF pressure - traction on the intracranial structures in the upright position - Compensatory increase in blood volume venodilatation

    INCIDENCE
    Needle tip Needle gauge Incidence of PDPH design (%) Quincke 22 36

    Quincke
    Quincke Quincke

    25
    26 27

    325
    0.320 1.55.6

    Needle tip Needle gauge Incidence of PDPH design (%) Whitacre


    Whitacre Whitacre Whitacre

    20
    22 25 27

    25
    0.634 014.5 0

    Tuohy

    16

    70

    SPINAL NEEDLE TIP DESIGNS QUINCKEN [L], SPROTTE [M] & WHITACARE [R]

    SUSEPTIBILITY
    1. Younger age compared to Elderly people

    2. Obstetrics Patients
    3. Females 4. Larger Spinal Needles 5. Cutting Spinal Needles

    PRESENTATION
    1. Onset

    2. Symptoms - Headache An increase in severity of the headache on standing is the sine qua non of post dural puncture headache - Nausea & Vomiting - Diplopia

    DIAGNOSIS
    1. History - Dural puncture - Symptoms of a postural headache 2. Diagnostic lumbar puncture 3. MRI 4. CT myelography

    5. Radionuclide myelography

    DIFFERENTIAL DIAGNOSIS
    01. Viral, chemical or bacterial meningitis 02. Intracranial haemorrhage 03. Cerebral venous thrombosis 04. Intracranial tumour 05. Non-specific headache 06. Cerebral infarction 07. Sinus headache 08. Migraine 09. Drugs (e.g. caffeine, amphetamine) 10. Pre-eclampsia

    DURATION
    - 72% of headaches resolve within 7 days - 87% resolve in 6 months - With no treatment, over 85% of post-dural puncture headaches will resolve within 6 weeks

    TREATMENT
    The aim of management 1. Replace the lost CSF

    2. Seal the puncture site 3. Control the cerebral vasodilatation

    1. Psychological 2. Supportive therapy 3. Posture

    4. Abdominal binder
    5. Pharmacological 6. Epidural blood patch

    EPIDURAL BLOCK
    - Thicker Needles

    - Technique Space Detection - Loss of Resistance - Hanging Drop

    - Single Shot or Continuous Catheter technique - Test Dose??

    COMPLICATIONS
    Intra Operatively -

    1. Dural Tap
    2. Total Spinal Anaesthesia 3. Shivering

    4. Nausea/Vomiting
    5. Urinary Retention

    Post Operatively -

    1. Headache
    2. Epidural Haematoma 3. Epidural Abscess

    PRECAUTIONS FOR NEURAXIAL ANAESTHESIA AND ANALGESIA IN PATIENTS TAKING ANTICOAGULANT DRUGS

    MINIMUM DELAY BETWEEN LAST DOSE OF ANTICOGULANT DRUGS & PLACEMENT/REMOVAL OF EPIDURAL CATHETER
    1. Unfractionated Heparin - 02 - 04 hrs 2. LMWH - 10 - 12 hrs 3. Aspirin - 0 day 4. Clopidogrel - >/= 07 days 5. Abciximab - 2 days 6. Fondaparinux - No epidural

    MINIMUM DELAY AFTER PLACEMENT/ REMOVAL OF EPIDURAL CATHETER & NEXT DOSE OF ANTICOAGULANT DRUGS
    1. Unfractionated Heparin - 0.5 - 01 hr 2. LMWH - 02 -12 hrs 3. Aspirin - Immediate 4. Clopidogrel - Immediate 5. Abciximab - 02 - 04 hrs 6. Fondaparinux - No epidural

    CONTRAINDICATIONS TO NEURAXIAL ANAESTHESIA AND ANALGESIA


    PT APTT Platelet Count INR > 1.5 > 40 Seconds < 50,000 cells/ml

    - If INR is increasing, the cut-off level would be INR > 1.5 - If INR is decreasing, the cut-off level would be INR >1.2

    FASTING RECOMMENDATIONS TO REDUCE THE RISK OF PULMONARY ASPIRATION


    - Recommendations apply to healthy patients undergoing elective procedures - Not intended for women in labor

    - The fasting periods noted apply to all ages

    Ingested Material

    Minimum Fasting Period (hrs) 2 4 6 6 6

    Clear liquids Breast milk Infant formula Non-human milk Light meal

    - Clear liquids include water, fruit juices without pulp, carbonated beverages, clear tea & black coffee - Non-human milk is similar to solids in gastric emptying time

    - A light meal typically consists of toast & clear liquids. Meals that Include fried or fatty foods or meat may prolong gastric emptying time. Both the amount & type of foods ingested must be considered when determining appropriate fasting period

    REFERENCES
    - British Journal of Anaesthesia, 2003, Vol. 91, No. 5, 718-729 - Millers Textbook of Anaesthesia, 6th Edition - Aitkenhead Textbook of Anaesthesia, 4th Edition - Oxford Handbook of Anaesthesia, 1st Edition - www.asahq.org - www.nda.ox.ac.uk/wfsa

    THANK YOU

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